- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $933.25 / $3,090.30 / $6,760.83
| Facility | | $933.25 | $3,090.30 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $562.34 / $851.14 / $2,511.89
| Professional | | $562.34 | $851.14 | $2,511.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $933.25 / $1,548.82 / $17,378.01
| Facility | | $933.25 | $1,548.82 | $17,378.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,445.44 / $1,584.89
| Professional | | $1,318.26 | $1,445.44 | $1,584.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,365.16 / $7,413.10 / $19,498.45
| Facility | | $4,365.16 | $7,413.10 | $19,498.45 |